Enrollee/Legally Responsible Person
Witness
Date
Date
1
Created 10/12
Rev. 3/13 Request to Review/Amend Record

Enrollee Name:
Medical Record#:
Address:
Telephone:
Enrollee Date of Birth:
Date/s of Entry to be amended/corrected:
Reason for Amendment:
Please identify incorrect or incomplete information entered in your medical record. Explain why the information is incorrect or incomplete and indicate what the information should say.
Do you need this correction/ amendment sent to anyone to whom we may have disclosed the information in the past? If so, please indicate the name and address of the individual or organization.
I have read the attached Alliance Behavioral Healthcare policy regarding my right to amend or correct information contained in my medical record. I understand that Alliance Behavioral Healthcare, under certain circumstances, may deny my request for amendment. Further, I understand that if Alliance Behavioral Healthcare denies my request for an amendment, he/she will provide a written denial outlining the basis for the denial.
Signature of Enrollee or Legal Representative Date
*************************************************************************************
For administrative use only
Date Amendment Request received:
If denied, reason for denial:
________ Medical information not created by this organization
Accepted Denied (circle one)
________ Medical information is not available to the patient for inspection as required by law (e.g. psychotherapy
notes)
________ Medical information is not part of the patient’s health record
________ Medical information is accurate and complete
1 st denial letter sent: 2 nd denial letter sent:
Name of Staff member:
Title:
Comments of Reviewer:
Signature of 1 st Reviewer:
Signature of 2 nd Reviewer:
Date of review:
Date of review:
2
Created 10/12
Rev. 3/13 Request to Review/Amend Record

Each enrollee of Alliance Behavioral Healthcare has the right to request access to inspect and obtain a copy of your health information for as long as the information is maintained by Alliance in a designated record set. If we do not maintain the health information that is the subject of your request for access, but we know where the requested information is maintained, we will inform you where to direct your request for access .
Access to Review Record
Each request for access to your personal health information must be in writing by completing page 1 of the
“
Request to Review/Amend Record
” form. We must process your request in a timely manner, not to exceed 30 days (with a one-time 30-day extension if the record cannot be accessed within the original 30 days). Alliance will notify you in writing of any extension outlining the reason for the delay.
The request will be reviewed to determine whether access can be granted or denied. Reasons for denial, without providing you an opportunity for review or appeal include:

Psychotherapy notes;

Information compiled in reasonable anticipation of, or for use in a civil, criminal, or administrative action or proceeding;

Health information maintained by covered health care components that is subject to the Clinical
Laboratory Improvements Amendments of 1988;

Information created or obtained in the course of research that includes treatment, may be temporarily suspended for as long as the research is in progress, provided the consumer was previously informed of the suspension and consents to it;

Access to records that are subject to the Privacy Act, 5 U.S.C. 552a may be denied if the denial of access would meet the requirements of that Act; and

Protected health information that was obtained from someone other than a health care provider under a promise of confidentiality and the access required would be reasonably likely to reveal the source of the information.
If access is granted, the records are provided. If access is denied, you will receive a denial letter. You have a right to a second level review. If the denial is upheld after the second level review, you will receive a second letter of denial. Designated Alliance clinical staff may deny access to information in certain circumstances if:
1) it is believed such access is reasonably likely to endanger the life or physical safety of yourself or another person;
2) the information makes reference to another person (other than a health care provider) and access may cause substantial harm to that person; or
3) the access is requested by your legally responsible person and access could cause substantial harm to you or another person.
If access is denied in whole or in part, we will determine if access to any part of the record is allowed. We will provide you with a written explanation as to the reason for the denial that includes the basis for the denial and if applicable, a statement of your review rights. If access to the record is denied, you can request that copies of the record be sent to a physician or psychologist of your choosing.
Amendments to personal health information
Alliance shall act on your request for amendment no later than 60 days after receipt of the request. If we are unable to act on the request for amendment within the 60-day time limit, Alliance will extend the time frame for such action by no more than 30 days. We will provide you with a written statement of the reasons for the delay and the date by which the covered entity will complete its action on the request.
3
Created 10/12
Rev. 3/13 Request to Review/Amend Record

If Alliance grants the requested amendment in whole or in part, we will take the following steps:

All documents in the designated record set that needs to be amended will be identified.

Allow insertion of the amendment on the Request to Review/Amend Record form as an addendum to the contested portion of the designated record set; however, the original portion of the designated record set may not be deleted.

Inform you that the amendment is accepted and obtain your identification of and agreement to have
Alliance notify the relevant persons with which the amendment needs to be shared.

Make reasonable efforts to inform and provide the amendment within a reasonable time to those identified by you and to any business associates who have copies of the health information being amended.
Alliance may deny a request to amend your health information if it is determined that the information:

Was not created by Alliance (or the originator of the information is no longer available to evaluate the request for amendment);

Is not part of a designated record set;

Is excluded from the information to which a consumer may request access; or

Is accurate and complete
Alliance will provide you with a timely written denial that informs you of the following:

The basis for the denial;

Your right to submit a written statement disagreeing with the denial and how you may file such a statement;

A statement that if you do not submit a statement of disagreement, you may request that the agency include your request for amendment and the denial with any future disclosures of the health information that is the subject of the amendment; and

A description of how you may complain.
We will permit you to submit a written statement disagreeing with the denial of all or part of a requested amendment and the basis of such disagreement. Alliance may reasonably limit the length of a statement of disagreement. Alliance may prepare a written rebuttal to your statement of disagreement. Whenever such rebuttal is prepared, Alliance will provide a copy to you.
Alliance will, as appropriate, identify the health information in the designated record set that is the subject of the disputed amendment and append or otherwise link the following to the designated record set:

Your request for amendment;
 Alliance’s denial of the request;

Your statement of disagreement with the request denial, if any; and
 Alliance’s rebuttal to your statement of disagreement with a request denial, if any.
If you submit a statement of disagreement, we will include the appended material in the designated record set in accordance with above or at the discretion of Alliance. Include an accurate summary of such information with any subsequent disclosure of the health information to which the disagreement relates. If you have not submitted a written statement of disagreement, Alliance will include your request for amendment and its denial, or an accurate summary of such information, with any subsequent disclosure of the health information only if you have requested such action.
4
Created 10/12
Rev. 3/13 Request to Review/Amend Record

Complaints
You may file a complaint to Alliance by either completing the Privacy Complaint form located on our website
( www.alliancebhc.org
) or by contacting the Privacy Officer at:
Alliance Privacy Officer
4600 Emperor Boulevard
Durham, NC 27703
Phone: (800) 510-9132
You may also file a written complaint by mail or fax to the Secretary of the Department of Health and Human
Services (DHHS) at:
Office for Civil Rights
U.S. Department of Health and Human Services
61 Forsyth Street, SW-Suite 3B70
Atlanta, GA 30323
Phone: (404) 562-7886
TDD: (404) 331-2867
Fax: (404) 562-7881
Guidelines for Submitting a Complaint
• The complaint to the Secretary must be filed in writing, either on paper or electronically.
• The complaint must include the name “Alliance Behavioral Healthcare” and describe the acts or omissions
believed to be in violation of the Privacy Rules.
• The complaint must be filed within 180 days of when you knew or should have known that the act or omission
occurred.
• We have designated staff available to provide you with assistance and/or a form to file the complaint.
If you file a complaint with our Privacy Officer or the Secretary of DHHS, we will not take any action against you or change our treatment of you in any way.
Created 10/12
Rev. 3/13
5
Request to Review/Amend Record